Monitoring of children’s health

1. Monitoring of children’shealth Prof.Dr. Emel Gür İ.Ü Cerrahpaşa Tıp Fakültesi Çocuk Sağlığı ve Hastalıkları ABD Sosyal Pediatri Bilim Dalı

2. ExaminationMaintanceImprovementof health To prevent diseases and disabilities Early diagnosis and treatment To prevent deaths of babies and children Support to families for healthy raising of children Aim

3. Support to families Health education Consultancy Family planning Prevention of diseases Follow up of growth and development Appropriate feeding according to age Immunisation Activities Early diagnosis and treatment History Physical examination Lab. tests

4. Steps in monitoring of childrenshealth Follow up Meeting and history Examination of growth and development Detailed physical examination Screening Immunisation Health trainning and counseling Mother’s questions Determination of the next appointment

5. Monitoring of thegrowth Aim; to follow up the health, to detect health problems in its early stage , to prevent malnutrition At each examination weight, height and head circumference sholud be correctly measured, standart growth curve should be evaluated and it sholud be interpreted in the right way Parents should participate actively in the examination of growth

6. Bebek ve Çocuk İzlem Protokolü. T.C Sağlık Bakanlığı AÇSAP Genel Müdürlüğü. Genelge 2008/45.

11. GrowthcurvesforTurkishchildren

12. WeightcurvesforTurkishchildren

13. Markedcurves of children’sweight good dangerous attention catch up of growth

14. Monitoringandsupport of development(Guide formonitoring of chidren’sdevelopment) Is there any worry about child’s development, hearing, talking, understanding, use of hands and body movements? Can your child explain what he wants? What is your child understanding? What is he doing with his hands and fingers, what is the way he is making his body movements? What is the way he communicates with the family members and foreigners? Can you give us information about the way he is playing games?

15. Screening of development • Screening of developmental problems is useful for monitoring of risk infants • Denver II is a reliable screening test for the children at their first 6 years of life • Development, personal and social inteligence,fine and rough motor skills and language are examined by Denver II test

16. Strabismus Vision problems Hearing problems Interruption of growth Child abuse Teeth problems Cornea reflex Allen, Snellen tables OAET Measurement of growth and weight History , inspection, physical examination Physical examination Screening of EarlyChildhood

17. Hypothyroidism Phenylketonuria Hydrocephalus Cleft palate Congenital heart deseases Hernies Undescended testis Hypospadias Serum T4/TSH Guthrie Measurement of head circumference Physical examination Physical examination Physical examination Physical examination Physical examination Screening of newborn

18. Screening Routine screening History Inspection Physical examination Laboratory tests Sensorial tests Additional screening (family history, ethnicity etc..)

19. Scoliosis Parasitosis Behaviorialdisorders Physical examination Stool smear History , examination Screening of school-agechildren

20. Screening of Newborn

21. NewbornScreening Programs Phenylketonuria screening program, which has been implemented in 22 cities by support of the Turkish Republic ministery of health since 1987, was carried out by Istanbul University Faculty of Medicine, Hacettepe University Faculty of Medicine, Cumhuriyet University Faculty of Medicine, Dokuzeylül University Faculty of Medicine in 74 cities. General newborn screening programs in Turkey; 1993 Phenylketonuria 2007 Congenital hypothyroidism 2008 Biotinidase deficiency Since 2006 Newborn metabolic screening tests are being analysed at Ankara central laboratory and İstanbul Hıfzıssıhha Institute.

22. Time of takingbloodsamplefornewbornscreeningtests Blood should be taken in the first 48-72 h, after first enteral feeding (appsolutely before child is being discharged) For the PKY ve biotinidase screening at least 48 h enteral feeding (75 kcal/kg/day) Blood sample taken in the first 24 h can give a false negative result for PKY and biotinidase; for hypotiroidism it can give a false positive result Total parenteral nutrition can lead to falce negative results If the blood sample was taken too early or before feeding, it should be repeated in 1-2 weeks

23. Takingbloodsamplefornewbornscreening • Heel should keep warm (max. 42 C, heated by wet towel for 3 min) and under the level of hearth • It should be cleaned by 70% isopropyl alcohol and left to dry • Plantar face of the heel is punctured at its media or lateral side by steril lancet (at depth of 2.0-2.4 mm)

24. Use of Guthriecardsat newbornscreening Thefirstdrop of blood is cleanedbygauze, laterdropsmakecontactswithGuthriecards an bythisway 5 markedareasarefullfilled (heelshould not be squeezed, cartonshould not be suppressed ) Front andrearside of thecard’smarkedsectionshould be filledoutcompletely. However, bloodshould be absorbed at onlyoneside. Blood sampleshould be dried at horizontalposition at roomtemperature at least 3 hours. Thereshould not be anycontact at card’smarkedsectionbeforeandaftertakingbloodsample.

25. Right blood sample Unequal spread of blood Blood clots at sample Wrong filled circles Poor saturation

26. Recordinganddeliveryof Guthriecard ID, address, name of hospital , number of sample , date of birth date of blood sampling, prematurity, transfusion, time and way of feeding should be written on Guthrie card. Card should be covered in an envelope and immediately delivered to City Health Council , Center of Public Health (Fatih Grup Başkanlığı ) and Refik Saydam Hıfzısıha center. Screening status should absolutely be recorded at file of the baby.

27. Screening of Phenylketonuria Frequency 1/10 000 (Turkey: 1/4 500) Each year 250-300 patient, from 20-25 persons one is carrier Caracterized by sever motor-mental retardation Detected by fluorescent immunoassay (FIA) In the case of positive result test should be repeated (FIA, enzyme,paper chromatography, HPLC, Tandem mass spectrometry) Ozalp I, Coşkun T, Tokatli A, Kalkanoğlu HS, Dursun A, Tokol S, Köksal G, Ozgüc M, Köse R. Newborn PKU screening in Turkey: at present and organization for future. Turk J Pediatr. 2001;43 (2):97-101.

28. FLOW CHART FOR PHENYLKETONURİA 3.-5.day BLOOD SAMPLE Access to lab. 2-3 day İNAPPROPRİATE BLOOD SAMPLE APPROPRİATE BLOOD SAMPLE REPEATED BLOOD SAMPLE SCREENING LAB. FA LEVEL ( FIA METHOD) 72 h Access to lab 3-5 day NORMAL ≤2 mg/dl 2.1 – 3.9 mg/dl ≥4 mg/dl REPETEAD BLOOD SAMPLE 72 h ≤2 mg/dl ≥2.1 mg/dl DEPARTMENT FOR PEDİATRİC FEEDİNG AND METABOLISM HPLC method FA>120µmol/L and FA/tirozin>2 follow; FA>360 µmol/L treatment.i 3 day

29. Biotinidasedeficiency General frequency 1:60 000 Turkey 1:11 763 (117 case/year) Convulsion, hypotonia, ataxia, vision, andhearingloss, skin rash, mentalretardation, acidosis, coma, death Screening is performedbycolorimeric test If biotinidase deficiency is +, the spectrophotometric test is performed Baykal T, Huner G, Sarbat G, et al. Incidence of biotinidase deficiency in Turkish newborns. Acta Paediatr, 1998;87(10):110-3. Tanzer F, Sancaklar M, Büyükkayhan D. Neonatal screening for biotidinase deficiency: results of a 1-year pilot study in four cities in central Anatolia. J Pediatr Endocrinol Metab. 2009;22(12):1113-6.

30. FLOW CHART FOR BİOTİNİDASE DEFFİCİENCY 3.-5. DAY BLOOD SAMPLE UNAPPROPRİAE BLOOD SAMPLE APPROPRİATE BLOOD SAMPLE Access to lab. 2-3 day REPETEAD BLOOD SAMPLE SCREENİNG LAB. (colorimetric method) 72 h ENZYME ACTİVİTY (+) ENZYME ACTİVİTY ↓ or (-) Access to lab. 3-5 day REPETEAED BLOOD SAMPLE ENZYME ACTİVİTY (+) ENZYME ACTİVİTY ↓ or (-) 72 h DEPARTMENT FOR PEDİATRİC FEEDİNG AND METABOLISM Spectrophotometric method <3.5U/L (enzyme activity as %) Enzyme activity <%30 partial, <%10 total enzyme defficiency

31. Hypothyroidism Frequency of 1/3500-4000 (World), Turkey:1/2700 Severe growth retardation and mental retardation Heelblodsampleforscreening: TSH and T4 level TSH; primary andcompensated hypothyroidism is recognized, central hypothyroidism is skipped (lowfalse positivity) T4; primary, secondary, tertiaryhypothyroidism, TBG deficiency, hipertiroksinemi, slowrise in level is diagnosticforcon. hypothyroidism (compensatedhypothyroidismcould be skipped) Yordam N, Calikoğlu AS, Hatun S, Kandemir N, Oğuz H, Tezic T, Ozalp I. Screening for congenital hypothyroidism in Turkey. Eur J Pediatr.1995;154(8):614-6. Update of newborn screening and therapy and congenital hypothyroidism. Pediatrics 2006;117(6):2290-303. Lafranchi SH. Newborn screening strategies for congenital hypothyroidism: an update. J Inherit Metab Dis. 2010 Mar 2. [Epub ahead of print]

32. FLOW CHART FOR CONGENİTAL HYPOTİROİDİSM BLOOD SAMPLE Access to lab. 2-3 day INAPPROPRİATE BLOOD SAMPLE APPROPRİATE BLOOD SAMPLE REPEATED BLOOD SAMPLE SCREENING LAB. TSH level 72 h <15 mlU/L 15-50 mlU/L >50 mlU/L Access to lab. 3-5 day REPEATED BLOOD SAMPLE NORMAL <15 mlU/L ≥15 mlU/L 72 h DEPARTMENT FOR PEDIATRIC ENDOCRINOLOGY APPROPRIATE LAB. Serum T4 <10µg/dl;TSH>10mlU/L CONSULTATION OF SPECIALIST

33. Developmentaldysplasia of thehip • DDH frequency 1.49% • Should be screened at all newborns by physical examination • It should be repeated at each examination till child start to walk • Ortoloni and Barlow test are reliable at first 3 months • Restricted abduction at hip is the most reliable after 3 months of age • Ultrasound is helpfull before 4 months of age, X ray is helpfull for diagnosis after 6 months of age • Children with positive signs should be refered to ortopedist • For risk infats ultrasound is suggested at the period of 4-6 weeks (breech birth, musculo-skeletal deformities, positive family history etc.)

35. Examination of thehipjoint Barlow maneuver Subluxation, unstable hip Ortoloni maneuver Dislocated hip

36. Examination of thehipjoint Restricted hip abduction (<60º)

37. Prevention of developmentalhipdisplasia Keeping hip at abduction and slightly flexion , keeping knee at flexion is the most appropriate position for the normal development of the hip joint Swaddle and supine positions are not recommended (side position is also risky) Keeping legs with upside down position increase the risk Baby diapers bond should be wide ; clothes should not be narrow Appropriate carriage (baby sling)

38. Irondefficiencyanemia • Frequency of 40% among toddlers in our country • For term babies at 4-6 months, for preterm babies at 2-3 months of age iron storage is becoming sufficient . • İf iron defficiency lasts more then 3 months, it can lead to serious problems of development • In countries with frequency of more than 10%, for term healthy babies it is recommended to check up Hb/Hct at the age of 6-12 months • In our country iron is given profilactic (1mg/kg) to all term born children (breastfeeding and feeding with cow milk), starting at the age of 4 months and continuing for 1 year. Among preterm born children profilaxy starts at the age of 2 months. • Control Hb should be taken at the age of 9 months • Hb< 11 g/dl : treatment with iron and after 1 month control. Treatment should be continued at least for 3 months. • Hb controlu should be made at adolescence

39. Urinarytractinfections • Frequency: females 3%, males 1.1% • The main reason for the chronic renal insufficiency at underdeveloped and developing countries • Diagnosis and treatment on time is very important • Screening should be performed in the age of 5 year and in adolescency • Screening should be performed at fresh sample of urine by stick test • In the case of positive result, mycroscopic examination should be made • Detail examination of urine and urine culture should be taken at those with symptoms of infection

40. Screeningforcongenitalheartdiseases • Thehalf of thecongenitalheartdiseasescould be detected at thefirstnewbornphysicalexamination • Theearlydiagnosismakesprevention of heartfailure, hypoxemia, infectiveendocarditis • Itshould be examined at allnewbornsbyhistoryandphysicalexamination • Cardiovascularsystemshould be carefullyexamined at eachexamination • Femoral artery pulse palpation, auscultation of heartareveryimportantscreeningmethodes • EKO screening is recommendedforallbabies at risk at 16. GH

41. Hypertension • Frequency at children: 1-3% • Important for the heart, brain, kidney, eye complications • For healthy children tansion should started to be measured at the age of 3 years, and later on it should be measured at each examination • Measurement should be made at sitting position • Cuff height should be 80-100% of the mid-upper arm circumference or two thirds of the length of the upper arm • Hypertension; blood pressure above 95 percentile according to patients age and sex

42. Measurement of thearteriapressure Restingfor 3-5 min. beforemeasurement Measurementshould be made at sittingposition (forinfantssupineposition) Cuffshould be put at supportedrightupperarm Cuffshould be placed at two thirds of the length of the upper arm, it shouldsurroundcomplitelycircumference of thearm Cuffshould be placed2 cm abovethefossa cubitalis A stethoscope should be placed on palpable brachial artery pulsations

43. Measurementof thearteriapressure Cuff should be inflated 20-20 mm above sistolic blood pressure and should be deflated with the speed of 2-3 mmHg/sec. Sistolic blood pressure: point of the 1. korotkoff sound Diastolic blood pressure: point of 5. korotkoff sound disappears If the BP is high: it should be measured on the other arm and the other leg and measurement should be repeated 1 week later

44. Examination of thebloodpressuremeasurement At least three measurements of blood pressure According to sex and age; BP<90p= Normal: no need for folow up TA=90-95p.=borderline. No symptoms: follow up. TA=90-95p with symptoms: evaluation (urine, hemogram, urine culture, elektrolyts, urea,creatinine, uric acid , renal ultrasound, EKG ) TA>95 p =HT: advanced evaluation at hospital

45. Hyperlipidemia • Atherosclerotic changes begins at childhood age . • Annual risk evaluations should be done at all children after age of two • Histories such as coronary artery and cerebrovascular deseases or any sudden death caused by cardiological reasons before age of 55 at family should be interpreted. • T. cholesterol level>240 status of mother or father. • Histories such as obesity, hypertension, diabetes or smoking at child. • Cholesterol and lipid levels should be checked at children with risk factors. • Lipoprotein analysis should be done at children with t. cholesterol level>200 mg/dl. • Diet programs should be carried out once in each 5 years if LDL<110 mg/dl , once in each year if LDL=110-129 mg/dl , continuously if LDL>130 mg/dl.

46. HearingScreenings • The frequency of hearing loss is %1-3 at normal babies, %2-4 at babies remained in intensive care. • Age of application to a health care institution is 3.8 years in our country. • A serious two-sided hearing loss influences speech and cognitive development negatively • Aim is to determine the hearing loss before third month. • Initiation of treatment before sixth month has a significant effect at language development. • Newborn and infants should be screened with histories and physical examinations in a subjective way ; subjektif, childrens at pre-school period (3-4-5 years) should be screened with hearing tests in an objective way. • It is recommended that hearing tests should be done intermittently till the end of the period of adolescence.

47. Hearingscreenings at healthyinfants *Newborn : Auropalpebral reflex, recoil,moro reflex * First Month : recoil ,interruptions at feeding * 3-4 months : Begins to turn head toward the sound source * 4-7 months : Turns head completely toward the sound source * 9-13 months: Finds directly source and direction of the sound *21-24 months :Replies with short sentences against to the people who warns orally.

48. Childrenwith risk factors for hearing loss • Sensorineural hearing loss history at family • Birth weight <1500 g • Low apgar score (1.min<5, 5.min<7) • Intrauterine infection, bacterial meningitis • Ventilation more than 5 days . • Hyperbilirubinemia requiring blood exchange • Use of ototoxic drugs • AOM with effusion lasting along 3 months • Syndromes accompanying with hearing loss. • If otoacoustic emission test (OAE ) and brainstem evoked potentials (ABR)should be carried out at risky children, hearing loss can be reduced at %20 percentage , this should be carried out for all children at first 48 hours .

49. OAE should be carried out at all babies in first 48 hours after birth. OAE test reflects the sound energy originated at cells in the inner ear ; and measured by microphones at outer ear. If OAE test fails , repeating after two months, If repeating fails too, then auditory brainstem responses ( ABR ) test should be carried out. Audiometric hearing test should be done to all children in pre-school age (4 years old) Objective Hearing Screening

50. Screening of vision • Strabismus2-6%, refractiondisorders 20%, amblyopia 2-4% • Amblyopia; loss of visualacuity≥ 2/10 ordifferencebetweeneyes≥2/10 • Inthefirst 3 monthspermanentstrabismus, after 3. month of agepermanentandtemporarystrabismus is patologicaland it is themostcommonreasonforamblyopia • Ifstrabismuswas not treated in thefirst 6 years it leadstoamblyopia, after 12 years of ageamblyopiacould not be treated.